Healthcare Provider Details

I. General information

NPI: 1568471209
Provider Name (Legal Business Name): KONSTANTIN MOYSEYSTEV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 BEACH AVE
STATEN ISLAND NY
10306
US

IV. Provider business mailing address

372 BEACH AVE
STATEN ISLAND NY
10306
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-1555
  • Fax: 718-351-1635
Mailing address:
  • Phone: 718-667-1555
  • Fax: 718-351-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046174
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: